A recruitment maneuver increases oxygenation after intubation of hypoxemic intensive care unit patients: a randomized controlled study

Abstract

IntroductionTracheal intubation and anaesthesia promotes lung collapse and hypoxemia. In acute lung injury patients, recruitment maneuvers (RMs) increase lung volume and oxygenation, and decrease atelectasis. The aim of this study was to evaluate the efficacy and safety of RMs performed immediately after intubation.MethodsThis randomized controlled study was conducted in two 16-bed medical-surgical intensive care units within the same university hospital. Consecutive patients requiring intubation for acute hypoxemic respiratory failure were included. Patients were randomized to undergo a RM immediately (within 2 minutes) after intubation, consisting of a continuous positive airway pressure (CPAP) of 40 cmH2O over 30 seconds (RM group), or not (control group). Blood gases were sampled and blood samples taken for culture before, within 2 minutes, 5 minutes, and 30 minutes after intubation. Haemodynamic and respiratory parameters were continuously recorded throughout the study. Positive end expiratory pressure (PEEP) was set at 5 cmH2O throughout.ResultsThe control (n = 20) and RM (n = 20) groups were similar in terms of age, disease severity, diagnosis at time of admission, and PaO2 obtained under 10-15 L/min oxygen flow immediately before (81 ± 15 vs 83 ± 35 mmHg, P = 0.9), and within 2 minutes after, intubation under 100% FiO2 (81 ± 15 vs 83 ± 35 mmHg, P = 0.9). Five minutes after intubation, PaO2 obtained under 100% FiO2 was significantly higher in the RM group compared with the control group (93 ± 36 vs 236 ± 117 mmHg, P = 0.008). The difference remained significant at 30 minutes with 110 ± 39 and 180 ± 79 mmHg, respectively, for the control and RM groups. No significant difference in haemodynamic conditions was observed between groups at any time. Following tracheal intubation, 15 patients had positive blood cultures, showing microorganisms shared with tracheal aspirates, with no significant difference in the incidence of culture positivity between groups.ConclusionsRecruitment maneuver following intubation in hypoxemic patients improved short-term oxygenation, and was not associated with increased adverse effects.Trial registrationNCT01014299

Hypoxemia during surgery: learning from history, science, and current practice

“…8 A recent review of rapid sequence induction in children demonstrated a significant incidence of moderate and severe hypoxemia despite optimal pre-oxygenation. 9 Broader implementation of a standard methodology to optimize oxygenation after tracheal intubation, including alveolar recruitment maneuvers, 10 could be adequate to limit the degree of post-induction hypoxemia.…”

“…Prevention of these events can be achieved utilizing established methods (e.g., recruitment maneuvers) 10 and may be further improved by developing novel approaches (e.g., negative pressure ventilation). 12 The frequent occurrence of multifactorial threats to maintain optimal oxygenation supports our current anesthesia practice of oxygen supplementation and continuous O 2 monitoring.…”

“…9 L'application plus répandue d'une méthodologie normalisée afin d'optimiser l'oxygénation après l'intubation trachéale, comprenant notamment des manoeuvres de recrutement alvéolaire, 10 pourrait être utile si l'on souhaite limiter quelque peu l'hypoxémie après l'induction. Des événements subséquents peuvent également provoquer l'hypoxémie, comme par exemple l'apparition d'atélectasie, 11 la perte de respiration spontanée, et des problèmes au réveil tels que le laryngospasme, une paralysie résiduelle et l'hypoventilation dus aux sédatifs ou aux opioïdes.…”

“…Des événements subséquents peuvent également provoquer l'hypoxémie, comme par exemple l'apparition d'atélectasie, 11 la perte de respiration spontanée, et des problèmes au réveil tels que le laryngospasme, une paralysie résiduelle et l'hypoventilation dus aux sédatifs ou aux opioïdes. On peut prévenir ces événements en ayant recours à des méthodes établies (par ex., des manoeuvres de recrutement), 10 et la prévention peut être encore améliorée grâce à la mise au point de techniques innovantes (par ex., la ventilation en pression négative). 12 La survenue fréquente de menaces multifactorielles au maintien d'une oxygénation optimale appuie notre pratique actuelle de l'anesthésie, qui consiste en l'addition d'oxygène et le monitorage continu de l'O 2 .…”

Comparison of 2 Lung Recruitment Strategies in Children With Acute Lung Injury

“…Maneuvers designed to open the lung must be applied with sufficient pressure over sufficient time to reach diseased lung. Recruitment maneuvers (RMs) may be used to reverse episodes of profound hypoxemia, ap-plied empirically following periods of derecruitment (eg, suctioning), 4 or utilized as part of a ventilation strategy. 5 …”